Levophed Infusion in the Presence of Septic Shock and SIRS

Though dopamine has long been the vasopressor of choice in EMS, recent studies have shown support for the use of Levophed (norepinephrine) in SIRS and septic shock. SIRS, or Systemic Inflammatory Response Syndrome, is an inflammatory state affecting the entire body that oftentimes is a response to infection. SIRS is related to sepsis in that patients with sepsis generally meet the criteria for SIRS in addition to having an infection.

Levophed is classified as an endogenous catecholamine. It is a direct alpha and beta adrenergic receptor agonist. Its alpha effects tend to be stronger than its beta. In addition to its vasoconstrictive properties, it also shows an increase in venous return as well as increased preload. For patients with suspected infection it is important to document findings such as fever, tachypnea, tachycardia, and hypotension. These signs can indicate SIRS.

Patients that are experiencing profound hypotension in relation to these other signs and symptoms should receive fluid boluses immediately. If hypotension is refractory to this, Levophed should be considered. Typically if you have administered a liter of fluid, and you aren’t seeing any type of improvement, more aggressive means should be contemplated.

Septic shock has a mortality rate of 40-70%. We are frequently the patient’s first contact with a medical provider and early recognition is key in timely treatment. There are many protocols in place that may differ from facility to facility in caring for the patient with septic shock. These vary from multiple antibiotics to lab tests and time spent in the hospital.

As EMS providers, we generally provide care that is needed immediately in the prehospital setting to insure the patient is delivered safely and (hopefully) in better condition to the hospital. So, it’s no stretch of the imagination to predict that most providers that may have a short transport time would prefer to leave the Levophed infusion to the hospital. There are many factors in considering this: being uncomfortable with drip rates and/or medical math, or a critical patient that would benefit from immediate transport, among other things. Though each case will be different, it is judicious to consider using Levophed if a patient meets the above criteria. Transport need not be delayed to start the infusion. Many services provide detailed directions because it is a lesser used infusion. There are also many apps and drug calculators available to EMS providers to safeguard a proper administration. Below, we have attached a simple calculation chart with the most common setup regionally. Keep in mind that it will differ from service to service.

DRUG CALCULATION FOR MCG/MIN

______ mcg/min X 60 ÷ _____ mcg/mL = ______mL/h

Dosage concentration pump setting

IF YOU RECEIVE A PATIENT ON A PUMP ALREADY

______ mcg/mL X ______ mL/h ÷ 60 = ______ mcg/min

Concentration pump setting dosage

COMMON CONCENTRATION DRIP CHARTS

This chart is strictly for a 4mg (4,000mcg) vial that is mixed in a 250ml bag of D5W.

2mcg

8gtts/min

4mcg

15gtts/min

6mcg

23gtts/min

8mcg

30gtts/min

10mcg

38gtts/min

12mcg

45gtts/min

This chart is strictly for an 8mg (8,000mcg) vial that is mixed in a 250ml bag of D5W.

2mcg

4gtts/min

4mcg

8gtts/min

6mcg

11gtts/min

8mcg

15gtts/min

10mcg

19gtts/min

12mcg

23gtts/min

We hope that this was helpful, but also understand that eyeballing 23gtts/min without a pump can be difficult! Let us know what you think in the comments section; also if your department carries a different concentration we’d love to hear about it so we can get it up here for other providers.